<form id="formPayment" method="post" action="{$form_submit_url}">
    <input type="hidden" id="action" name="action" value="BUTTON_PRESSED"/>{$hiddenFields}
	{if $errors}
		{foreach from=$errors item=error}
			<p class="error"">[[{$error}]]</p>
		{/foreach}
		<br/>
	{/if}
	<fieldset>
        <div class="orderInfo"><strong>[[Order Information]]</strong></div>
        <div class="orderInfo">[[Invoice Number]]: {$invoiceInfo.invoiceNumber}</div>
        <div class="orderInfo">[[Description]]: {$invoiceInfo.description}</div>
		<div class="orderInfo">[[Total]]: {$GLOBALS.settings.transaction_currency} {tr type="float"}{$invoiceInfo.totalPrice}{/tr}</div>
        <div>&nbsp;</div>
    </fieldset>
    <fieldset>
        <div class="inputName" ><strong>[[Credit Card Information]]:</strong></div>
        <div class="inputReq" >&nbsp;</div>
        <div class="inputName">
            <img src="{image}/creditcards/visa.gif" width="43" height="26" title="[[Visa]]" alt="[[Visa]]" />
            <img src="{image}/creditcards/mastercard.gif" width="41" height="26" title="[[MasterCard]]" alt="[[MasterCard]]" />
            <img src="{image}/creditcards/amex.gif" width="40" height="26" title="[[American Express]]" alt="[[American Express]]" />
            <img src="{image}/creditcards/discovery.gif" width="40" height="26" title="[[Discover]]" alt="[[Discover]]" />
        </div>
    </fieldset>
    <fieldset>
        <div class="inputName" >[[Card Number]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
            <input type="text" class="input_text" id="card_number" name="card_number" value="{$formFields.card_number}" maxLength="16"/>
			<br/>([[enter number without spaces or dashes]])
        </div>
    </fieldset>
    <fieldset>
        <div class="inputName" >[[Expiration Date]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
            <select id="exp_date_mm" name="exp_date_mm">
				{foreach from=$monthList item="month"}
					<option value="{$month}" {if $formFields.exp_date_mm == $month}selected="selected"{/if}>{$month}</option>
				{/foreach}
            </select> [[Month]]
            <select id="exp_date_yy" name="exp_date_yy">
			{foreach from=$yearList item=yearList}
                <option value="{$yearList}" {if $formFields.exp_date_yy == $yearList}selected="selected"{/if}>{$yearList}</option>
			{/foreach}
            </select> [[Year]]
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Credit card CSC value]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="csc_value" name="csc_value" value="{$formFields.csc_value}" maxLength="20"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[First Name]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="first_name" name="first_name" value="{$formFields.first_name}" maxLength="50"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Last Name]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="last_name" name="last_name" value="{$formFields.last_name}" maxLength="50"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Billing Address]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="address" name="address" value="{$formFields.address}" maxLength="60"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Zip Code]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="zip" name="zip" value="{$formFields.zip}" maxLength="60"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Country]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
            <select id="country" name="country">
				<option value="">[[Select Country]]</option>
				{foreach from=$CountryList key="Country" item="countryCode"}
					<option value="{$countryCode}" {if (!empty($formFields.country) && $formFields.country == $countryCode) || (empty($formFields.country) && $curUserCountryInfo.country_code == $countryCode)}selected="selected"{/if}>{$Country}</option>
				{/foreach}
            </select>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[City]]:</div>
        <div class="inputReq">&nbsp;*</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="city" name="city" value="{$formFields.city}" maxLength="40"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[State]]:</div>
        <div class="inputReq">&nbsp;</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="state" name="state" value="{$formFields.state}" maxLength="40"/>
        </div>
    </fieldset>
    <fieldset><div class="inputName" >[[Email]]:</div>
        <div class="inputReq">&nbsp;</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="email" name="email" value="{$formFields.email}" maxLength="255"/>
        </div>
    </fieldset>
    <fieldset>
		<div class="inputName" >[[Phone Number]]:</div>
        <div class="inputReq">&nbsp;</div>
        <div class="inputField" >
			<input type="text" class="input_text" id="phone" name="phone" value="{$formFields.phone}" maxLength="25"/>
		</div>
	</fieldset>
    <fieldset>
        <div class="inputName" >&nbsp;</div>
    </fieldset>
    <fieldset>
        <div class="inputName" >&nbsp;</div>
		{capture name="trPayNow"}[[Pay Now]]{/capture}
        <div class="inputName" ><input type="submit" value="{$smarty.capture.trPayNow|escape:'quotes'}" /></div>
    </fieldset>
</form>